PowerPoint® Presentation by Jim Foley

© 2013 Worth Publishers

Chapter 15Therapy

Chapter Overview

Major types of psychotherapy include psychoanalytic, humanistic, behavior, cognitive, and individual, group, and family psychotherapy.

Issues in psychotherapy include culture, gender, values, effective factors and types, and the evaluation of psychotherapy effectiveness.

We’ll also look at biomedical therapies such as drugs, brain stimulation, surgery, and lifestyle change.

Finally, we’ll briefly consider the prevention of psychological disorders.

Therapy refers to how mental disorders are

treated, with the help of the knowledge base of

psychology.

In the first pages of this chapter, what mental health problem did Kay Jamison have?What benefits did her therapist provide?– “He saw me through madness, despair…” – “He was very tough… very kind”– “He understood more than anyone else…” – “He taught me… [about] mind and brain”– “Psychotherapy heals.”

Introductory Case Study

History of Mental Health TreatmentWhen people have displayed unusual behaviors rooted in the mind, these people have often been locked away or “treated” using old ideas of mental illness.

Old ways of getting rid of “the evil spirits” include: beating them out of people. bleeding them out. letting the spirits out through holes drilled in the skull.

Other Reforms in TreatmentSeeing the “insane” as ill instead of “possessed”Treating them with tenderness, not harshnessHousing them in hospitals rather than locking them up in asylumsDeveloping psychotherapeutic treatments, medications, and community supports to allow life outside hospitals

Reforms in Treatment

This chair was designed to be an improvement in medical treatment. It was meant to have a calming effect on people with mania.

Psychotherapy: an interactive

experience with a trained professional,

working on understanding and changing behavior,

thinking, relationships, and emotions

Current Forms of Therapy

Biomedical therapy:the use of medications and other procedures acting directly on the

body to reduce the symptoms of mental

disorders

There are various forms of psychotherapy.Combining Therapies

An eclectic approach uses techniques from various forms of therapy to fit the client’s problems, strengths, and preferences.

Medications and psychotherapy can be used together, and may help the each other achieve better reduction in symptoms.

Noteworthy Schools of Psychotherapy

Psychoanalysis, psychodynamic therapy

Humanistic, client-centered therapy

Behavior therapy, using conditioning

Cognitive therapy, changing thoughts

Sigmund Freud’s legacy carried on today

Carl Rogers and Abraham Maslow

B.F. Skinner and Ivan Pavlov applied to people

Aaron Beck and Albert Ellis, reducing errors and distress

PsychoanalysisSigmund Freud (1856-1939) found that the unusual symptoms of patients sometimes improved when repressed inner conflicts and feelings were brought into conscious awareness.

Psychoanalysis refers to a set of techniques

for releasing the tension of repression

and resolving unconscious inner

conflicts.

Techniques:Free association: the patient speaks freely about memories, dreams, feelingsInterpretation: the therapist suggests unconscious meanings and underlying wishes to help the client gain insight and release tension

The therapist may see unconscious meaning in resistance, dreams, and transference.

Resistance: the therapist notices times when the

patient seems blocked in speaking about certain subjects

Interpretation in Psychoanalysis

Dreams: there may be themes or “latent

content” behind the plot of a patient’s dream

Transference: the patient may have reactions

toward the therapist that are actually based on feelings toward someone

from the past

Psychodynamic Therapy

Less intensive version of psychoanalysis Fewer sessions per week

and fewer years Less theory about sex, id,

and superego The focus is on improved

self-awareness and insight into unconscious thoughts and feelings which may be rooted in past relationships.

In addition to insight, therapists suggest changes in patterns of thinking and relating to others.

Interpersonal Therapy

A further extension of psychoanalysis

The goal is less focused on insight, and more on relational behavior change and symptom relief.

The focus is less on the past, and more on current feelings and relationships including the interaction with the therapist.

Humanistic therapy attempts to support personal growth by helping people gain self-awareness and

self-acceptance.

Humanistic Therapies

“Client-centered therapy”

is Carl Rogers’s name for his

style of humanistic

therapy.

Humanistic psychology (Abraham Maslow and Carl Rogers) emphasizes the human potential for growth, self-actualization, and personal fulfillment.

Humanistic vs. Psychoanalytic Therapy

Humanistic psychotherapy

Psychoanalytic psychotherapy

Goal Promote growth Cure mental illness

How to improve

Take responsibility for feelings and actions

Bring unconscious conflicts into conscious awareness

Role of therapist

Provide an environment in which growth can

occur

Provide interpretations (e.g. of dreams, resistance and

transference)

Content of therapy

Conscious feelings, actual self and ideal self Unconscious conflicts

Time focus The present and future The past

Let insight and goals come from the client, rather than dictating interpretations.

Being non-directive

Be yourself and be truthful; don’t put on a therapist façade.

Being genuine

Help the client learn to accept themselves despite any weaknesses.

Being accepting and showing unconditional positive regard

Demonstrate careful attention to the clients’ feelings, partly by reflecting what you hear the client saying.

Being empathetic

Style of the Client-Centered Therapist

Showing Empathy Through Active ListeningClient-centered therapists show that they are tuning in to clients’ feelings and meanings.1.Summarize, paraphrase

“So your father wasn’t around much?”

2.Invite clarification and elaboration

“When you say ‘anxiety,’ what does that feel like to you? What is going on in your body and thoughts?”

3.Reflect Feelings“It seems like you are disappointed; am I right?”

Behavior Therapy

Sometimes, insight is not helpful to recover from some mental health problems. The client might know the right changes to make, but finds that it’s hard to change actual behavior.

Behavior therapy uses the principles of learning, especially classical and operant conditioning, to help reduce unwanted responses. These might include behaviors such as addictions, or emotions such as panic.

Classical Conditioning Techniques

Counterconditioning refers to linking new, positive responses to previously aversive stimuli.

If you have been conditioned to fear stores because you have had panic attacks there, you could be led into a store and then helped with relaxation exercises. The goal is to associate stores with relaxation, a state incompatible with fear.

Exposure Therapy A conditioned fear

can worsen when avoidance of the feared situation gets reinforced by a quick reduction in anxiety.

Guided exposure to the feared situation can reverse this reinforcement by waiting for anxiety to subside during the exposure. The person can

habituate to (get used to) the anxiety itself, and then the feared situation.

What mistake is Professor Gallagher

making here?

Hint: systematic desensitization

might have been more effective,

though less dramatic

Versions of Exposure TherapySometimes, exposure to the feared situation is too anxiety-provoking or impractical. In those cases, you can use:systematic desensitization. Beginning with a tiny reminder of the feared situation, keep increasing the exposure intensity as the person learns to tolerate the previous level. virtual reality therapy. This involves exposure to simulations, such as flying (below) or snakes.

The Bed-Wetting Alarm Example

18

Isn’t a bed-wetting alarm a form of operant conditioning? Doesn’t the child get a punishment for wetting the bed?Assuming the child is not wetting on purpose: the bed wetting is not an operant behavior, and the child cannot choose to avoid the alarm. The association that is made is between a biological state (a full and relaxing bladder), and sudden alarming wakefulness. This resembles classical conditioning.

Aversive ConditioningWhen a person has been conditioned to have a positive association with a drug...

Aversive conditioning can associate the drug with a negative response.

Operant Conditioning Therapy

Operant conditioning refers to the shaping of chosen behavior in response to the consequences of the behavior.

Behavior modification refers to shaping a client’s chosen behavior to look more like a desired behavior, by making sure that desired behaviors are rewarded and problematic behaviors are unrewarded or punished.

Applied behavioral analysis/application is used with nonverbal children with autism. It rewards behaviors such as sitting with someone or making eye contact, and sometimes punishes self-harming behaviors.

A token economy uses coins, stars, or other indirect rewards as “tokens” that can be collected and traded later for real rewards.

Applications of Operant Conditioning

Critiques of Behavior TherapyIs it ethical? Does it work?

It does often work, but extinguished behaviors and reactions do spontaneously reappear.

To ensure maintenance of changes, a transition is needed from artificial rewards to awareness of natural, environmental consequences.

To minimize ethical problems:acquire consent, at least of guardians.develop goals for treatment that are more humane than the alternative. For example, shaping autistic behavior is seemingly better than institutionalization.

And when it does, do the changes stick, without insights and other changes to hold the new behavior in place?

Since conditioning operates below conscious awareness, couldn’t people’s choices and reactions be manipulated without their consent?

Cognitive Therapies: TheoryBeing depressed and/or anxious involves negative thoughts and interpretations.

In the cognitive perspective, the cause of depression are not bad events, but our thoughts about those events.

Cognitive Therapies: Practice

Therapists might suggest other thoughts that the clients could have about their lives, or at least point out when clients jump to conclusions that make them feel worse.

Cognitive therapy helps people alter

the negative thinking that

worsens depression and anxiety.

Schools of Cognitive Therapy Albert Ellis’s rational-emotive behavior therapy– challenging irrational beliefs and assumptions

Aaron Beck’s cognitive therapy for depression– correcting cognitive distortions

Donald Meichenbaum’s stress inoculation training– practicing healthier thinking before facing a stressor,

disappointment, or frustration

Rational-Emotive Behavior Therapy

Albert Ellis showed how depression is worsened by irrational beliefs. These include depressing assumptions about the world such as “everyone should like me” or “I should never do anything wrong.”

Rational-Emotive Behavior Therapy [REBT] helps people: 1) notice that they are operating on self-defeating assumptions, and 2) reward themselves for replacing these assumptions with realistic beliefs. For example, a more realistic belief might be, “some people won’t like me, many will have no opinion; it doesn’t matter.”

Aaron Beck’s Therapy for Depression

Aaron Beck helped people see how their depression was worsened by errors in thinking such as catastrophizing, (interpreting current events as signs of the worst possible outcome). For example:

Beck’s style of therapy helps clients notice and challenge these errors in thinking.

“Now that I’ve made a mistake in my lecture, I’ve failed as a professor.

Students can’t take me seriously, and they can’t learn from me.”

Cognitive Behavioral Therapy

Using cognitive behavioral therapy, people with OCD are led to resist the urge to act on their compulsions, as well as to learn to manage obsessional thinking.

Cognitive behavioral therapy [CBT] works to change both cognitions and behaviors that are part of a mental

health disorder.

Family Therapy

Group Therapy

Self-Help Groups Self-help groups are led by group members instead of a therapist.

They can be much larger than group therapy, with less interaction.

The focus is more on support rather than on working on goals during the group session.

Group therapy assembles about six to nine people with related needs into a group, facilitated by a therapist, to work on therapeutic goals together. The benefits include: less cost per person.more interaction, feedback, and support.clients realize others share their problems and they are not alone.

Having a session with the whole family, at home or in the office, allows the therapist to work on the family system, that is, the family’s patterns of alliances, authority, and communication.

A related modality is couples/marital therapy.

Is Psychotherapy Effective?There are different measures of the value and effectiveness of psychotherapy:whether the client is satisfiedwhether the client senses improvementwhether the therapist sees improvementwhether there has been an observable, measured change in initial symptoms

What Causes Improvement?Even if clients do improve, is the improvement really caused by therapy? It could be:regression to the mean, drifting from initial crisis back to an average state.the client’s motivation to appear better in order to please the therapist or to justify the cost of therapy.

To track the effectiveness of an intervention, use a control group not receiving the intervention, or even a placebo group.

To measure effectiveness, use objective, observable measures of symptoms rather than relying on client or therapist perceptions.

Studying Treatment Outcomes

Understanding Outcome DataIf we find that even people in a control group (e.g. on a waiting list) showed improvement, is therapy a waste of time?

About 80 percent of untreated people have poorer outcomes than the average treated person.

Number of persons

People are more likely to improve with treatment.

Results of Outcome Research

Depression

Anxiety

Phobias

Bedwetting

Cognitive-behavioral

Psychodynamic therapy

Exposure therapy

Behavior conditioning

Some forms of psychotherapy have been found to be effective for certain problems:

Using Outcome Research in Therapy

Clinical decisions are made based on more than just outcome research.

Evidence-based practice refers to the use of outcome research about the effectiveness of different techniques to select therapeutic interventions.

Evaluating “Alternative” Therapies

When new cures emerge, they are often promoted with testimonials.

Problem:we don’t knowif those “cures” were really caused by the intervention. In addition, we don’t know how many people received no benefit from the intervention.

Solution: controlled studies with random assignment to non-intervention conditions.

Challenge: making sure the interventions are performed by people trained in that area.

In EMDR therapy, the therapist attempts to unlock and reprocess previous frozen traumatic memories. The therapist waves a finger or light in front of the eyes of the client, in order to integrate past and present, and left and right hemispheres.

Eye Movement Desensitization and Reprocessing (EMDR)

Some studies show EMDR is effective and some do not. Studies which did not show effectiveness were critiqued by the founder as being done without adequate training in EMDR. Is this a valid critique of the research?Research suggests that the effectiveness of EMDR, even when it does work, may not depend on the eye movement technique.

Light Exposure Therapy

Research supports the idea that daily exposure to bright light, especially with a blue tint, is effective in treating the depressive symptoms of seasonal affective disorder [SAD].

What do effective psychotherapy styles seem to have in common?

Hope: therapists assume the client has resources that can be used for recovery, and that improvement is possible

A new perspective: new interpretations and narratives (from “victim” to “survivor”) can improve mood and motivate change

The relationship: empathy, trust, and caring provide an environment for healthy growth

Client-Therapist DifferencesTherapists differ from clients (and from each other) in beliefs, values, cultural background, conversational style, and personality.Ways to serve diverse clientsTherapists should be receptive, respectful, curious, and seek understanding rather than assuming it. The therapist and client do NOT have to have similar backgrounds for effective therapy and a good therapeutic relationship. It is more important to have similar ideas about the function and style of therapy.

Therapists and their TrainingPsychotherapists ≠ psychologistsPsychologists (PhD, PsyD) do therapy plus intelligence and personality testing.Psychiatrists (MD, DO) prescribe medicine and sometimes do psychotherapy.Social workers (MSW) as well as counselors, nurses, and other professionals may be trained and licensed to diagnose and treat mental health disorders.

Selecting a Psychotherapist People with a variety of

different graduate degrees are able to provide psychotherapy.

Specific training and experience in the area of your difficulty is worth asking about.

What is most important is whether you and the therapist are able to establish an alliance. Some of this is trial and error. If problems arise, you can try working it out, but switching therapists is okay.

Biomedical Therapies

Biomedical therapies refer to physically changing the brain’s functioning by altering its chemistry with medications, or affecting its circuitry with electrical or magnetic impulses or surgery.

Interventions in the brain and body can affect mood and behavior.

Drug (Medication) TherapiesPsychopharmacology refers to the study of drug effects on behavior, mood, and the mind.

Antipsychotic Antianxiety Antidepressant

What they do

Reduces the symptoms of schizophrenia, especially “positive” symptoms such as hallucinations and delusions

Temporarily reduces worried thinking and physical agitation; might permanently erase traumatic associations

Improves mood and control over depressing and anxious thoughts

How they work

Blocking dopamine receptors

Slowing nervous system activity in the body and brain

Increasing levels of serotonin (sometimes norepinephrine) at synapses by inhibiting reuptake; possible neurogenesis

Side effects

Obesity, diabetes, and movement problems (sluggishness, twitching, or eventually tardive dyskinesia--odd facial/tongue and body movements)

Slowed thinking, reduced learning, dependence, and withdrawal

Dry mouth, constipation, and reduced sexual desire and/or response

Types of Medication

Inhibiting ReuptakeMany medications increase synaptic neurotransmitter levels; they stop the sending neuron from taking back its chemical messages.

Mood Stabilizers

ADHD “Stimulants”

What they do

Reduce the “highs” of mania as well as reduce the depressive “lows”

Help control impulses, and reduce distractibility and the need for stimulation including fidgeting

How they work

Under investigation

Blocking reuptake of dopamine from synapses

Side effects

Various; blood levels must be monitored

Decreased appetite

Types of Medication

Electroconvulsive therapy [ECT] induces a mild seizure that disrupts severe depression for some people.

This might allow neural re-wiring, and might boost neurogenesis.

Electroconvulsive Therapy (ECT)

Repeated Transcranial Magnetic Stimulation

Another option is repeated deep-brain stimulation using implanted electrodes.

Like ECT, these techniques may disrupt depressive electrochemical brain patterns.

A lobotomydestroys the

connections between the frontal lobes and the rest of the brain.

This decreases depression, but also destroys initiative,

judgment, and cognition.

Psychosurgery

Microsurgery might work by

disrupting problematic neural networks

involved with aggression or obsessive-

compulsive disorder.

Therapeutic Lifestyle ChangeWe can indirectly affect the biological components of mental health problems.Exercise can boost serotonin levels and reduce stress.Changing negative thoughts can improve mood and even rewire the brain. Mental health problems also can be reduced by meeting our basic needs for sleep, nutrition, light, meaningful activity, and social connection.

In addition to treating mental health disorders, some mental health professionals, especially social workers, also work to reduce the risk of mental health disorders. Such prevention efforts include:

support programs for stressed families.

community programs to provide healthy activities and hope for children.

relationship-building communication skills training.

working to reduce poverty and discrimination.

Preventing Psychological Disorders